CORD Best Practices

Clinical Teaching: An Evidence-based Guide to Best Practices from the Council of Emergency Medicine Residency Directors

Sreeja Natesan, MD* *Duke University, Division of Emergency Medicine, Durham, North Carolina John Bailitz, MD† †Northwestern University, Feinberg School of Medicine, Department of Emergency Andrew King, MD‡ Medicine, Chicago, Illinois Sara M. Krzyzaniak, MD§ ‡The Ohio State University Wexner Medical Center, Department of Emergency Medicine, Sarah K. Kennedy, MD¶ Columbus, Ohio Albert J. Kim, MD, MACM|| §University of Illinois College of Medicine at Peoria/OSF Healthcare, Department of Richard Byyny, MD# Emergency Medicine, Peoria, Illinois Michael Gottlieb, MD** ¶Indiana University School of Medicine, Department of Emergency Medicine, Indianapolis, Indiana ||Washington University in Saint Louis School of Medicine, Department of Emergency Medicine, St. Louis, Missouri #Denver Health Medical Center, Department of Emergency Medicine, Denver, Colorado **Rush Medical Center, Department of Emergency medicine, Chicago, Illinois

Section Editor: Tehreem Rehman, MD Submission history: Submitted December 3, 2019; Revision received March 30, 2020; Accepted April 9, 2020 Electronically published July 3, 2020 Full text available through open access at http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.2020.4.46060

Clinical teaching is the primary educational tool use to train learners from day one of medical school all the way to the completion of fellowship. However, concerns over time constraints and patient census have led to a decline in bedside teaching. This paper provides a critical review of the literature on clinical teaching with a focus on instructor teaching strategies, clinical teaching models, and suggestions for incorporating technology. Recommendations for instructor-related teaching factors include adequate preparation, awareness of effective teacher attributes, using evidence-based-knowledge dissemination strategies, ensuring good communication, and consideration of environmental factors. Proposed recommendations for potential teaching strategies include the Socratic method, the One-Minute Preceptor model, SNAPPS, ED STAT, teaching scripts, and bedside presentation rounds. Additionally, this article will suggest approaches to incorporating technology into clinical teaching, including just-in-time training, simulation, and telemedical teaching. This paper provides readers with strategies and techniques for improving clinical teaching effectiveness. [West J Emerg Med. 2020;21(4)985–998.]

BACKGROUND teaching.3 Moreover, EM faculty concerns over time constraints Emergency medicine (EM) is a dynamic specialty that and patient census variability are reflected in a decline of requires not only an acquisition of vast amounts of medical bedside teaching in the clinical setting.2,4-6 There is mounting knowledge, but also the ability to prioritize and task switch evidence that clinician educators often feel ill prepared to efficiently and effectively to combat the chaos, high patient teach in this dynamic clinical environment due to a lack of a volume, and variable acuity within a given shift. Additionally, consolidative resource.7-13 A set of guidelines may help assist in mounting pressures are placed on EM faculty to use less time the development of skills for educators to help bridge this gap. to care for a larger volume of patients while increasing patient However, the ED environment provides unique satisfaction scores, documentation, billing, and academic opportunities for clinical teaching due to the breadth of productivity.1,2All of these factors can make the emergency pathology, spectrum of acuity, and large number of clinical department (ED) a challenging environment for clinical encounters. When surveyed, students rated the ED as the

Volume 21, no. 4: July 2020 985 Western Journal of Emergency Medicine Clinical Teaching Best Practices from CORD Natesan et al. most valued rotation for learning opportunities.14 Therefore, Table 1. Oxford Centre for Evidence-Based Medicine levels of it is essential that all emergency clinicians who work with evidence.17 learners develop strong clinical teaching skills to maximize Level of evidence Definition this educational opportunity. This article provides a narrative 1a Systematic review of homogenous summary of the literature and best practice recommendations randomized control trial (RCT) for clinical teaching in medical education with a focus on their 1b Individual RCT application within the ED environment. 2a Systematic review of homogenous cohort studies CRITICAL APPRAISAL OF THE LITERATURE 2b Individual cohort study or a low-quality This article is the fourth in a series of evidence-based best RCT* practice reviews from the Council of Emergency Medicine 3a Systematic review of homogenous case- 15-17 Residency Directors (CORD) Best Practices Subcommittee. control studies With assistance of a medical librarian, we performed a search 3b Individual case-control study** of Embase, CINAHL, Ovid MEDLINE, and PsycINFO for articles published from inception to April 23, 2018, using 4 Case series or low-quality cohort or case- control study*** keywords and medical subheadings (MeSH) terms focused on teaching at the patient’s bedside. The full search strategy is 5 Expert opinion available in the Appendix. Bibliographies of all relevant articles *<80% follow-up; **includes survey studies; ***studies without were reviewed for additional studies. We used social media to clearly defined study groups. further augment the search by placing several calls on Twitter among the #FOAMed and #MedEd communities to gather additional article recommendations. Articles were screened Table 2. Oxford Centre for Evidence-Based Medicine Grades of independently by two of the authors to evaluate for any papers Recommendation.17 addressing the following three themes, which were determined Grade of evidence Definition a priori: instructor teaching strategies, clinical teaching models, A Consistent level 1 studies and incorporation of technology. We included articles if either author recommended inclusion. B Consistent level 2 or 3 studies or extrapolations* from level 1 studies The search yielded a total of 2,514 articles, of which 123 were deemed to be directly relevant for inclusion in this review. C Level 4 studies or extrapolations* from level 2 or 3 studies When supporting data were not available, recommendations were made based upon the authors’ combined experience and D Level 5 evidence or troublingly inconsistent or inconclusive studies of any level consensus opinion. The level and grade of evidence was provided for each best practice statement according to the Oxford Centre *“Extrapolations” indicate data were used in a situation that 17 has potentially clinically important differences than the original for Evidence-Based Medicine criteria (Tables 1 and 2). Prior to study situation. submission, the manuscript was reviewed by the entire CORD Best Practices Subcommittee. It was subsequently posted to the CORD website for two weeks for review and feedback from the entire CORD community. and setting relevant and achievable learning objectives by aligning the instructor’s and learner’s goals.3, 18-21, 23-29 INSTRUCTOR TEACHING STRATEGIES Patients are integral to bedside teaching by delivering a 1. Preparation unique perspective into their illness and educating learners As in most areas in life, preparation is the key to success about their disease course. The incorporation of patients into in clinical and bedside teaching. Adequate planning and clinical teaching adds a level of complexity for preparation preparation by the instructor, learner, and even the patient and planning.18 For bedside teaching, the instructor should will result in a much more effective learning experience for help prepare the patient and teaching team. This should be all involved.18 Preparing for didactic teaching, development done by setting expectations for the interaction with the of teaching scripts, and review of physical examination skills patient, such as maintaining a respectful and professional tone, prior to a shift can help alleviate instructor uncertainty and avoiding medical jargon, and involving the patient and his improve instructor confidence.5,6,18-22 or her family.30,31 When incorporating a patient into bedside Educators should consider priming the learner for the teaching, one should seek the patient’s permission first and set anticipated shift. Prior to the beginning of each teaching expectations prior to the encounter.6,20,21,23,25,26,30,32,33 However, shift, the instructor should work with the learner to set clear care must be taken not to create a blind spot in clinical teaching expectations and goals.3 This includes orienting the learner to by only focusing on specific sets of patients while avoiding the plan for clinical teaching, getting buy-in from the learner, others (e.g., those with communicable diseases or those deemed

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“difficult” patients).33 Patients’ autonomy should be respected and supervision to help foster a supportive relationship with at all times and they should be explicitly encouraged to ask the learner while providing an opportunity for growth.40,43,44 questions, clarify or amend data, and to provide feedback to Additionally, learners appreciate a positive attitude and their medical team.34,35 enthusiasm for teaching, as well as candor from teachers about their own knowledge deficits.18,27,45,46 Table 3 provides a 2. Instructor Characteristics summary of qualities considered by learners to be essential in Trust and support are important in clinical teaching. an effective clinical teacher.18,19,31,47,48 Establishing a collegial and supportive teacher-learner relationship is essential to create a culture that promotes 3. Knowledge Integration Strategies effective knowledge acquisition, professional growth, and Learners, while very eager and enthusiastic, may struggle lifelong learning habits.20,27,36-38 Learners have a tendency to with knowledge integration and retention. As an instructor, it mirror the behavior of instructors they feel are professional and is important to be cognizant of barriers to learning and how to competent. In knowing this, instructors should demonstrate overcome them. Several theories and strategies can be applied to empathy and compassion, teaching both medical knowledge clinical practice to help with knowledge acquisition and retention. and professionalism skills. Learners value instructors who can push them to their zone of proximal development (the A. Cognitive Load Theory difference between what a learner can do without help and The theory that the human brain can process only a finite what they can do with help) while maintaining a safe learning amount of information at one given time, creating a bottleneck environment.19,20,30,39-41 To help achieve this, educators should effect for learning is known as cognitive load theory.49-51 When avoid “read my mind” questions.19,42 If a learner is struggling the cognitive load is exceeded, learning and performance with a question, it can be beneficial to ask whether they are both impaired. This can be avoided by selecting relevant understand the question at hand or if it was too ambiguous. An teaching pearls that correspond to your learner’s level while appropriate balance should be maintained between autonomy avoiding teaching too much information at one time. In addition

Table 3. Features of an effective clinical teacher.18,19,31,47,48 Quality Example Attitudes • Efficient • Enthusiastic about medicine and teaching • Good bedside manner • Obviously interested • Positive attitude • Professional • Stimulates learners to think about topics Content Knowledge • Broad knowledge base • Clinical and technical skill competence • Challenges accepted dogma while admitting gaps in own factual knowledge • Clinical reasoning • Teaching ability Humanistic • Can admit limitations and say “I don’t know” • Compassionate and kind • Concerned • Fosters positive and supportive relationships with learners • Outgoing and friendly • Role model Leadership skills • Clear communication • Encourages active participation and team involvement • Establishes rapport with the group • Inclusive • Respects individuals • Sets goals and provides feedback • Supportive Learner-centered instructional strategies • Balance between didactics and bedside approaches • Challenges learners to continue to grow and think independently • Encourages learners to develop life-long learning skills

Volume 21, no. 4: July 2020 987 Western Journal of Emergency Medicine Clinical Teaching Best Practices from CORD Natesan et al. to the quantity of knowledge, educators should strive to reduce remind learners that interruptions frequently occur based extraneous load. Extraneous load is the part of the working on patient care demands. The responsibility falls on both memory that engages in work that is not crucial to completing the learner and instructor to revisit any interrupted teaching the learning task.50-53 Another technique in the clinical realm interaction to complete open discussions and teaching points.58 is to reduce extraneous activities to let the resident or student In caring for an acutely ill patient, it can be highly valuable focus more on specific tasks. for the learner to observe how a seasoned instructor provides medical care and communicates effectively with the patient, B. Interleaving family, and team members.4,59 After the event, the instructor Interleaving is when the learner alternates between semi- should debrief to allow discussion of medical decision- related topics rather than exclusively focusing on a single making, alternatives, and possible outcomes.3 area for an extended period of time.54,55 One practical clinical It is important for the instructor to be aware of the application of interleaving would be for the learner to first see learner’s mindset and select teaching opportunities for when a patient with shortness of breath who has congestive heart the learner will be most receptive.3 If the learner is falling failure, followed by a patient with shortness of breath due to behind on his or her current patients and has several new chronic obstructive pulmonary disease. The learner can then patients to see, the instructor should select a different time to compare and contrast the two different presentations. provide clinical teaching. Selecting a time when the learner is more receptive and has more available learning capacity will C. Spaced Repetition/Retrieval Practice enhance knowledge retention.50-53 Allowing time after clinical Spaced repetition is when the learner spreads out studying teaching to answer clarifying questions and explain the or recall of information over time to enhance retrieval and thought process of decision-making are essential for learning retention.54,55 Retrieval practice is another strategy focused and retention while providing guidance on future learning.19,41 on knowledge retention, wherein the learner is asked to Several strategies can be used to make on-shift teaching bring learned information from long-term memory back more efficient.6,32,60 The teacher could ask the learner to into use.54 One example using this concept is having the briefly review the literature for a given illness and then teach learner reiterate teaching points later in the shift, at sign this back to the instructor and other learners.23,30,31,37,60,61 This out, or even on a subsequent shift to help space the acquired will instill lessons of lifelong learning, such as strategies for knowledge and encourage recall of the information at a later accessing the literature on shift, and provides an opportunity time. Technology, in the form of flash card programs and for the learner to develop advanced knowledge on a specific applications (apps) (e.g., Quizlet, Anki, Flashcard Machine, topic while freeing up the teacher to see the patient. However, Study Blue, Study Stack) or in email form can also serve to asking the learner to review literature should not distract from remind the learner of information at a later date. the clinical experience or teaching, and care must be taken to not overuse this practice. Additionally, it is important for D. Importance of “Wait-time” and “Think-time” the teacher to set aside time for the learner to report back It is important to allow adequate time for the learner to the information they learned on their search. Setting a time process and recall information. When teaching, an instructor limit for the team (e.g., less than five minutes) to keep the typically poses a question and then waits for the learner to teaching session brief will support the learning environment reply, known as “wait time 1.” The time after the learner without compromising ED throughput.4,25 Additionally, this response is known as “wait time 2.” After proposing a question ensures that teaching points remain brief, thereby avoiding to a learner, previous studies have shown that an instructor the tendency to over-teach (i.e., covering an excessive amount typically waits an average of only 1.5 seconds prior to of material in a short time span).50,51 The use of a dedicated interjecting the answer.56,57 However, studies have found that teaching shift to protect the teacher and learner from tasks and waiting three seconds or longer (especially after “wait time 2”) duties that may distract from an instructional goal is another allowed the learner time to process the question and decreased effective strategy to optimize the time available for teaching in failure-to-respond rates, increased perception of caring the clinical environment.63 (thereby encouraging the learner to engage more actively), and increased the total number of responses received.56,57 5. Interprofessional Considerations Medicine has placed an increasing emphasis on the 4. Environmental and Timing Considerations importance of interprofessional teams for the delivery of Clinical teaching should never hinder or delay care for safe, efficient, cost-effective, and patient-centered care. patients, especially the critically ill; safety and the oath to Studies have found that non-physician colleagues who are “do no harm” take precedence over educational benefit.41 actively involved in bedside teaching can help to improve An instructor should select an appropriate “moment” for communication around the care plan, enhance provider clinical teaching while minimizing distractions and engaging satisfaction with communication, reduce errors, aid in the learners.6,23 In a busy ED environment, it is necessary to diagnosis, shorten hospital length of stay, and reduce total

Western Journal of Emergency Medicine 988 Volume 21, no. 4: July 2020 Natesan et al. Clinical Teaching Best Practices from CORD hospital charges.18,26,64 Even if other providers (e.g., nurses, The difference lies in the intent of the instructor toward the technicians, and pharmacists) are unable to be physically learner.68 While the Socratic method is a well-established present at the bedside, securing buy-in from interprofessional model for improving learning and recall, pimping has a providers and institutions for the importance of clinical less desirable intent. It is often viewed as a “sport” aimed teaching can minimize distractions during clinical teaching, at reinforcing the power dynamic and hierarchy of medical and improve the learning experience for all involved.6,25,65 training.69-73 Using increasingly difficult questions until the learner is unable to answer, the teacher shames or embarrasses the learner. Not surprisingly, this tactic impairs the trust relationship and inhibits learning. BEST PRACTICE RECOMMENDATIONS Questioning, in general, as a teaching method has been 54,56,57,74 1. Adequate preparation is crucial to the success of clinical found to be very efficient and effective. Students teaching. This includes setting clear expectations, priming have been shown to better recall knowledge if it is taught the learner, and seeking patient permission prior to bedside after asking a question.75 Using this technique, advanced teaching (Level 2b, Grade B). learners can be challenged while still teaching novices by 2. Learners will emulate behaviors of physicians they perceive targeting teaching and communication to meet the learner’s as competent and professional. Instructors should capitalize 23,27,30,36,37,40,42,44,60,67,76 on teachable moments and model efficient bedside history specific needs. To determine a learner’s and examination skills, communication styles, respect, existing knowledge, skills, and gaps, teachers can use probing compassion, and humanism (Level 2b, Grade B). questions (e.g., “why?” and “how would you approach…?”) 3. Consider reducing cognitive load, interleaving, using to guide individualized, specific teaching to the learner, spaced/retrieval practice, and increasing wait times after regardless of his or her level of training.4,18,19,23,28,41 Low-level asking questions to allow the learner time to process and questions can be used to assess factual recall, while higher- respond (Level 2a, Grade B). 4. During critically ill patient encounters, allow time to level questions assess problem-solving skills, analysis, and 24,30,32,34,36,37,40,42,43 debrief after the event. Also, consider incorporating short synthesis of the information. It is important to bedside teaching points during a patient’s evaluation push a learner from basic knowledge into critical thinking and (Level 5, Grade D). problem-solving skills through questioning. One strategy to 5. Incorporate additional members of the care team (e.g., help improve learning when approaching less familiar topics nurses, pharmacists, technicians) into clinical teaching is to provide basic starting points to create the scaffolding for encounters (Level 2b, Grade B). further problem-solving. However, when using questions as part of clinical teaching, it is essential that the learner feel safe to answer incorrectly with an emphasis on learning rather than CLINICAL TEACHING MODELS “correct answers.”68 It is important to use a variety of teaching strategies in Three types of questioning have been found to be the the ED and tailor them to the individual learner and situation. most effective for learning: broadening, targeting, and up-the- Being creative and innovative with teaching techniques ladder.44 Broadening involves asking “what if” scenarios to ensures that the sessions are memorable and meaningful for add educational examples beyond the current case. Targeting learners.28 We highlight several, well-described teaching is the practice of asking specific questions to specific team models and describe how they can be used in the ED members. The up-the-ladder technique (also referred to as including the Socratic method, Aunt Minnie, the One-Minute “step-up questioning”) occurs when the teacher asks the Preceptor (OMP), SNAPPS, ED STAT, teaching scripts, and same question to progressively more advanced learners. An bedside presentation/rounds. Table 4 includes a summary advantage of the up-the-ladder technique is that it respects the of each of these teaching techniques with a description and educational advancement order and avoids the challenges of example of how to implement them clinically. Additional having a junior learner respond once a more senior learner has resources for those interested in learning more are available answered incorrectly.77 in the Appendix. When using the Socratic method, it is important to identify the avoidant learner and gently draw him or her into A. Socratic Method the discussion. This may be facilitated by beginning with In the Socratic method, the instructor poses a series of simple questions or those that you previously have confirmed questions to a learner. One recent study found that this was the learner is able to answer correctly. While it is important to the most frequently used teaching method in the ED and was incorporate evidence-based medicine into teaching, questions used more often among higher-acuity patients, with more that are overly advanced or not familiar to the team should be senior residents, and when multiple learners were present.66 minimized as they have been shown to be less effective.40,44,78 In contrast, “pimping” (as it has been colloquially known) Finally, lowering the stakes of the Socratic method may is an alternate approach dating back to 17th century London be accomplished by incorporating humor, explicitly stating and is frequently confused with the Socratic method.67,68 expectations, and refraining from ego-driven discussions.

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Table 4. Commonly described clinical teaching models. Technique Implementation Pearls and Pitfalls Socratic Method Types of Questions: Best with higher patient acuity and • Broadening: Asking “what if…” questions and changing the details of a flow, as well as team teaching with case to make it more interesting. Example: ‘‘How would the management learners of different levels. change if the patient were 25 versus 75 years old?’’ • Targeting Questions: Directing questions at specific team members based Avoid alienating the learner with on their level of training. Example: For a student: “What are the most arcane questions. common bacteria that cause community-acquired pneumonia?” For a junior resident: “How do we decide if a patient with pneumonia needs to Avoid material that most/all of the be admitted?” For a senior resident: “How do we recognize and manage team is unfamiliar with. complications of pneumonia?” • Up-the-Ladder Questions: Ask the same question of the medical student, junior resident, and finally the senior resident if needed. Example: “In this patient with a recent variceal bleed, what treatments should we consider (student)? What do you think (junior resident)? Any additional considerations (senior resident)?” Aunt Minnie Pattern recognition: “If the lady across the street walks like your Aunt Minnie Best with lower patient volume and dresses like your Aunt Minnie, she probably is your Aunt Minnie, even if and acuity, and with learners able you cannot identify her face.” to perform a history and physical examination in a timely manner. Steps: 1. The learner evaluates the patient and then presents only the chief Efficient in teaching typical complaint and the presumptive diagnosis. presentations in common 2. The learner begins the patient note while the teacher evaluates the patient. illnesses. 3. The teacher discusses the case with the learner, gives feedback, and discusses pattern recognition for the presentation. Avoid with rare or atypical 4. The teacher reviews the learner’s write-up and signs the medical record. presentations and complex cases. One-Minute Steps: Best with high acuity patients and Preceptor (OMP) 1. Get a commitment from the learner on what they think is going on with more advanced learners. the patient. 2. Probe for supporting evidence to explore the learner’s understanding. Avoid in a busy ED with frequent 3. Teach general rule(s) pertaining to the patient and case. task interruptions unless completed 4. Reinforce what was done correctly and provide positive feedback to at the bedside. the learner. 5. Correct learner mistakes. SNAPPS Steps: Facilitates active adult learning 1. Summarize the history and physical examination. through dialogue with the preceptor, 2. Narrow the differential diagnosis to the most important. management planning, and 3. Analyze the differential by discussing the diagnosis and probabilities. identifying issues for further learning. 4. Probe the preceptor by asking questions about uncertainties and alternative approaches. Avoid in a busy ED with frequent 5. Plan patient management together. task interruptions unless completed 6. Select a related clinical issue for additional self-directed learning. at the bedside. ED STAT Steps: Designed for the complex 1. Expectations: Orient the learner to the ED, how the teacher and learner environment of the ED. will work together, and clarify expectations. 2. Diagnosis of the Learner: To make the teaching more relevant, Incorporates teaching and determine their learning objectives. feedback into one tool. 3. Set-Up: Use a specific patient care scenario to pose a question that will be used as the foundation for the teaching point. Determination of learner’s needs 4. Teach: Focus teaching on high-yield, concise, and relevant information to can help optimize clinical teaching. the learner with generalizability to other similar patient case presentations. 5. Assess and Give Feedback: Provide constructive and nonjudgmental feedback, include self-assessment as the foundation for preceptor feedback. 6. Teacher Always (Role Model): Realize that the learner is always watching and implicitly learns a great deal. Be aware of verbal and non- verbal communication cues (body language). Acknowledge statements as facts or opinions. ED, emergency department; STAT, strategies for teaching any time.

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Table 4. Continued. Technique Implementation Pearls and Pitfalls Teaching Scripts Tips: Avoid too much content to be • Instructors should have quick and specific teaching talks readily covered in a concise manner. available to review common topics. • Scripts should be short teaching points prepared ahead of time. Preparation is essential. Bedside Tips: Best when teaching team are able Presentations • Set the stage for your learners, patient, and family beforehand. to all round together. • At the bedside, ask the patient and family to listen to the presentation first. Then provide any clarifications afterwards. Must set expectations. • Assign roles to team members such as providing feedback on presentations, entering orders, or starting the patient note while the Avoid medical jargon. presentation is given. • Consider combining with the Socratic method, OMP, or SNAPPS at the bedside.

The emphasis should be placed on positive reinforcement C. One-Minute Preceptor (OMP) and framing questions as “learning opportunities.”77 Trainees The OMP model was initially described in 1992 by Neher should be reminded that more can be learned from incorrect and colleagues as a method to efficiently balance teaching while answers than correct ones, as incorrect answers shed light simultaneously providing effective patient care.84 This model is into the learner’s knowledge gaps. The Socratic method is particularly well-suited for the busy ED environment. The OMP frequently combined with many of the techniques that follow is a learner-centered model of instruction that is based on five to enhance learning and retention. microskills, as described in Table 4.58,84-88 The OMP model has shown high satisfaction among both B. Aunt Minnie learners and instructors with learners preferring the OMP model In the ED, many diagnoses occur through pattern recognition over the traditional precepting model.86 When evaluating the by aligning the history and physical examination with prior OMP, instructors have stated that it was more effective and experiences and expertise. The “Aunt Minnie” approach is a efficient than the traditional model, allowing them to provide teaching method focused on learning pattern recognition or more information in the same amount of time.89 Multiple studies heuristics for facilitating diagnostic efficiency. This is ideal for have demonstrated that teachers using the OMP feel more typical presentations of common, low-to-moderate acuity clinical confident in their ability to assess the learner’s knowledge and complaints and allows learners to increase their repository of clinical reasoning skills.86,89,90 patient experiences as they develop their clinical gestalt. This The OMP model depends on the accuracy and completeness strategy is based on the principle that, “if the lady across the street of information gathered by the learner. With more experienced walks like your Aunt Minnie and dresses like your Aunt Minnie, learners, such as a senior EM resident, this model may be she probably is your Aunt Minnie, even if you cannot identify implemented rapidly in one interaction from start to finish. With her face.”79 On a deeper level, this is informed by the concept more novice learners, modifications may be necessary to allow of System 1 (e.g., unconscious, automatic) and System 2 (e.g., the instructor the opportunity to assess the patient and gather any slow, effortful) thinking.80 This method can be used in the ED missing data. Regardless, the fundamental theme of encouraging to efficiently balance clinical care while incorporating clinical learners to commit to a diagnosis and plan is crucial to help shape teaching of learners.79,81 their critical thinking and decision-making skills. For an instructor, it is important to recognize when this technique is appropriate (e.g., common ambulatory complaints) D. SNAPPS (Summarize, Narrow, Analyze, Probe, Plan, and when the model should not be used (e.g., rare or complex Select) diseases).82,83 In the latter, learners may need to use a more The SNAPPS model emphasizes active learning by strategic approach (i.e., System 2 thinking).82,83 This also incorporating opportunities for the learners to ask the provides an opportunity for educators to teach learners how instructor questions regarding uncertainties and alternative to develop their gestalt. The Aunt Minnie method relies on an approaches, as well as guiding self-directed, future learning. instructor with a good foundation of clinical experience to help Although faculty training and ongoing commitment is facilitate the formation of pattern-recognition skills for the required, SNAPPS does not require significantly more learner. The instructor should not be afraid to share his or her time than traditional teaching.91,92 A simple refinement of own uncertainty and doubt with the learner in more complex the SNAPPS technique incorporates the PICO (Patient, cases to prevent the formation of incorrect associations. Intervention, Comparison, and Outcome) approach to frame

Volume 21, no. 4: July 2020 991 Western Journal of Emergency Medicine Clinical Teaching Best Practices from CORD Natesan et al. clinical questions to guide additional self-directed learning.93 and not about, and there should be mindful physical positioning Multiple studies have reported that utilization of the between the physician, learner, and patient.22,25,103 SNAPPS model results in numerous benefits when compared With adequate preparation, an instructor can add structure with traditional teaching and the OMP model. These benefits and depth to the teaching session to maximize the learning include increases in learner satisfaction, differential diagnosis opportunity, even if presenting patient complaints are limited.18 generation, expression of clinical reasoning, active engagement Several different models of bedside rounds exist that can be with teachers, generation of teaching points, opportunities for adapted to the ED, including basic science rounds (focus on self-directed learning, and clinical skills development.91,92,94-98 pathophysiology, signs, and symptoms); problem-oriented rounds (focus on prioritizing and managing the presenting problem list); E. ED STAT (Emergency Department Strategies for Teaching and clinical skills rounds (focus on history-taking and physical Any Time) examination skills).18 ED STAT is the first tool specifically designed for the There are several benefits to having learners present to complex learning environment of the ED with easy-to-follow the supervising clinician at the patient’s bedside. By moving steps, allowing incorporation of clinical teaching and feedback away from the computer or busy workstation, the focus into a single model. This model has been shown to increase shifts to the patient.102 Learners are able to directly observe the confidence in preceptors’ teaching and is designed for how experienced clinicians interview, examine, reason, and educators of all experience levels and backgrounds.99 Aside communicate with patients and their families. In addition, from demonstrating an increased knowledge of teaching supervising clinicians can immediately clarify presentations strategies specific to the ED, this technique has also been and physical examination findings. associated with an increased satisfaction and confidence in However, this approach has potential challenges. Learners teaching abilities by the individual.99 may feel increased pressure to present all of the facts and provide a comprehensive management plan while patients may not F. Teaching Scripts want more sensitive issues disclosed in group teaching sessions. Teaching scripts are quick, specific, previously created Residents may also fear that answering questions incorrectly teaching talks designed to review common complaints seen in the in front of their patients will jeopardize their patient-physician ED. Having these teaching scripts prepared ahead of time allows relationship and undermine their ability to care for that patient. for efficient teaching during a busy ED shift.4,22,100 For example, To avoid this, the faculty can direct questions to learners not when a patient presents with possible pulmonary embolism, being involved in direct care of that specific patient.4 Alternatively, able to quickly summarize the diagnostic approach with a figure instructors can help mitigate this by guiding learners to identify or and references for additional reading can reduce the educator’s by demonstrating a particular finding.35 workload while ensuring high-quality knowledge dissemination. Instructional content for teaching scripts can include medical knowledge, communication skills, procedural training, and time BEST PRACTICE RECOMMENDATIONS management strategies. To prevent cognitive overload, instructors 1. Use questions to engage students and residents in active should focus on one topic and limit the teaching to a short learning. Combine the use of low-level questions to assess time period.41 While some teaching opportunities will present knowledge and high-level questions to assess problem- themselves based on a particular patient complaint, others can be solving skills. Make sure to create a supportive, safe learning created by asking learners about theoretical scenarios.100 environment (Level 2b, Grade B). 2. Consider OMP to promote a learner-centered model of instruction. This tool is well-received by both learners G. Bedside Presentations and Rounds and instructors due to its focus on five microskills while Although initially a clinical teaching approach used in incorporating feedback (Level 2b, Grade B). inpatient medicine, bedside presentations and rounds can be 3. Consider using SNAPPS to promote active participation incorporated into the ED environment and may prove beneficial and engagement for both learners and educators (Level for patient care. During bedside rounds, all team members should 1b, Grade B). be introduced, and the comfort and privacy of the patient should 4. Considering using ED STAT to help foster an environment of 101 learning in the complete ED environment. It is designed for be maintained at all times. The patient should be oriented to educators of all experience and backgrounds and will increase the goal of the clinical teaching session prior to the interaction preceptors’ confidence in teaching. (Level 2b, Grade B) and be informed that there may be theoretical discussions (e.g., 5. Prepare ahead by having brief, specific, pre-created teaching differential diagnosis development, what-if scenarios) about their scripts designed to review common ED complaints to allow for illness.19,20,30,32,42,102 Of note, some experts believe that hypothetical efficient teaching during a busy ED shift (Level 2b, Grade B). scenarios are best left for discussion away from the patient’s 6. For bedside presentations, always orient the patient to 30 expectations prior to the interaction. Use patient-centered bedside to avoid confusion. Patient-centered communication communication, while being cautious with hypothetical (both verbal and non-verbal) should be used. As such, a body part situations in front of the patient, to facilitate a successful should not be referred to as “it.” The patient should be talked to experience (Level 2b, Grade B).

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INCORPORATING TECHNOLOGY having to look them up and evaluate them in real time, can The use of technology can help promote learning. As help ameliorate this. clinical teaching continues to evolve, the use of technology and innovative bedside teaching approaches will increase. B. Simulation (including Task Trainers and In Situ Learners who are involved in simulation rather than Simulation) traditional, paper-based learning have been shown to Clinical procedures have been identified as one core area demonstrate better retention skills.104 However, the use of to improve the efficiency and effectiveness of critical care technology is not just limited to formal didactics and can be education, specifically given the need to balance patient safety used in a variety of formats, including just-in-time training, with opportunities for learners to practice procedures.60 Strategies task trainers, in situ simulation, and telemedicine. to bridge this gap include learning that uses computers, task trainers, and simulation. The use of simulation to enhance clinical A. Just-in-Time Training teaching and learning continues to increase rapidly in the form of The learning needs and preferences of medical student both in situ simulation and procedural training. and resident learners continue to evolve. Digital natives crave Task trainers can serve as a safe alternative for reinforcing immediate information and prefer the integration of technology the muscle memory necessary for many of the tasks required in the learning process.105-107 One particular teaching modality, of an emergency physician. These can range from phantom just-in-time training (JITT), incorporates both technology and limbs for peripheral intravenous line placement to transvenous immediate, high-yield information to satisfy digitally-savvy pacing or pericardiocentesis models. Use of task trainers learners. JITT is a method of training where topic-specific allows evaluation of procedural competencies, provides a safe education occurs in a focused, concise manner just prior to environment for learning and fine-tuning skills, and allows for performing the task. The literature most commonly focuses on troubleshooting common errors that may occur in these high- using short, predefined educational content, such as a video stakes procedures without the added pressure of patient and with simulation for procedural-based competency. time constraints. The learner can practice placing an ultrasound- The advantages of JITT include minimizing training time, guided peripheral line on an ultrasound phantom model prior to the ability to visualize the procedure prior to performing it, performing the procedure on a patient. and allowing prompt return to clinical duties.108 As such, this In situ simulation refers to simulation performed in the is ideal for a high-volume ED setting. Additionally, JITT has clinical care setting. Simulation offers the benefit of experiential demonstrated positive effects at the learner, patient, and system learning in a realistic environment and can be run during levels, while also generally being enjoyed by learners.108 any clinical shift. Simulation allows the opportunity for JITT has previously been studied for splint application.109,110 interdisciplinary interactions and communication training. This When compared with reading textbooks, watching a brief can range from high fidelity (e.g., mannequins) to low fidelity JITT instructional video before splinting was shown to yield (e.g., mock cases in an empty patient room).118 Technology can faster learning times and more successful splint applications.110 facilitate these simulations by using stored images or videos, as Another study assessed JITT for intraosseous needle placement well as a number of simulation smartphone apps. and defibrillator use in a pediatric ED. JITT significantly increased comfort levels and the ability to perform the C. Telemedicine procedure independently by the trainee. Moreover, the use Wearable platforms enable learners to view how they of a dedicated JITT room in the clinical environment is both are perceived by patients and facilitate novel debriefing feasible, effective, and can lead to improved resident confidence approaches when attendings are not in the room during the with fewer supervisor-reported procedural interventions.108,111,112 initial patient encounter. Google Glass is a wearable platform However, JITT may not be helpful for all types of procedures with a head-mounted optical display that is lightweight, and training with some research showing conflicting success voice-activated, and provides the opportunity for technology- rate for certain procedures, such as pediatric intubation and assisted education.119,120 This platform allows audiences infant lumbar puncture.113,114 and learners to visualize what the operator is seeing in real Importantly, in the era of mounting technology and time, thereby allowing multiple learners to experience an easy availability, it is vital to screen the JITT resources educational benefit from a single experience.104,120 This can for quality and applicability prior to incorporation into also be used by learners to review and engage in self-reflection clinical practice.115,116 One study performed a systematic based on the encounter.121 Many of the features that clinical search of YouTubeTM to assess videos focused on teaching learners deem as important to clinical education can be ophthalmoscopy.117 Out of more than 7,000 videos, they accomplished using this model.122,123 However, it is important identified 27 (0.4%) that were suitable for teaching this to be conscious of patient privacy and the Health Insurance skill; however, none of them included all of the elements for Portability and Accountability Act. Moving forward, it is a thorough education on ophthalmoscopy. Pre-identifying imperative that medical educators keep abreast of emerging resources and having them ready for learners, rather than educational technologies including personalized learning,

Volume 21, no. 4: July 2020 993 Western Journal of Emergency Medicine Clinical Teaching Best Practices from CORD Natesan et al. mobile technologies, and learning analytics. Such technology CORD Best Practice Committee 2019-2020 has the potential to enhance learning and clinical competence within the clinical environment.60 Michael Gottlieb, MD – Co-Chair Rush University Medical Center

Sreeja Natesan, MD – Co-Chair BEST PRACTICE RECOMMENDATIONS Duke University 1. Use just-in-time training instructional videos to facilitate asynchronous teaching and procedural skills (Level 1b, John Bailitz, MD Grade B). Northwestern University, Feinberg School of Medicine 2. Incorporate a variety of stimuli (eg, imaging, electrocardiograms, ultrasound videos) into clinical shifts to enhance teaching and engagement of the learner (Level Brian Barbas, MD 2b, Grade B). Loyola University 3. Consider employing in situ simulation as an effective educational strategy when teaching in the clinical Jennie Buchanan, MD environment (Level 2b, Grade B). Denver Health Medical Center 4. Consider incorporating telemedicine and wearable platforms such as Google Glass to enhance teaching and feedback during clinical encounters (Level 2a, Grade B). Richard Byyny, MD Denver Health Medical Center

LIMITATIONS Guy Carmelli, MD This review has several important limitations to consider. University of Massachusetts Medical School First, while our search methodology was comprehensive, some articles may nevertheless have been missed in the current Molly Estes, MD review. We minimized the risk by reviewing all related studies Loma Linda University in the bibliographies of included articles, reaching out to content and topic experts, undergoing pre-submission review Katja Goldflam, MD and approval by the CORD community, and placing several Yale University calls via social media for further resources. Another limitation is the dearth of experimental studies specifically within the Andrew Grock, MD ED setting. When robust, ED-specific educational outcomes University of California - Los Angeles data were not available, we used studies from other fields and expert opinions. Thus, some proposed interventions may not be Jaime Jordan, MD as effective in the ED setting and further studies are needed to University of California - Los Angeles establish their efficacy in our learning environment. Andrew King, MD CONCLUSION The Ohio State University Because clinical teaching is a critical tool in the education and development of all physician trainees, it is vital to have Krystin Miller, MD a strong foundation of the available techniques and methods The Ohio State University for clinical teaching. Our work provides a critical review of the literature on clinical teaching for residency education with Melissa Parsons, MD a focus on EM. Recommendations were given for instructor University of Florida - Jacksonville teaching considerations, clinical teaching strategies, and options for incorporating technology into clinical practice. Alexander Sheng, MD We hope this manuscript will inform readers on strategies and Boston Medical Center techniques for successful clinical teaching. Brian Wood, MD ACKNOWLEDGMENTS St. Joseph’s Medical Center We would like to thank the Council of Emergency Medicine Residency Directors in Emergency Medicine for their support of our committee and this project. We would also like to thank our clinical librarian, Lauren Yaeger, from Washington University - St. Louis.

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Address for Correspondence: Sreeja Natesan, MD, Duke University, 15. Gottlieb M, King A, Byyny R, Parsons M, Bailitz J. Journal club in Division of Emergency Medicine, 1320 Erwin Road, PO Box 3096, residency education: an evidence-based guide to best practices from Durham, NC 27710. Email: [email protected]. the Council of Emergency Medicine Residency Directors. West J Conflicts of Interest: By the WestJEM article submission agreement, Emerg Med. 2018;19(4):746-55. all authors are required to disclose all affiliations, funding sources 16. Parsons M, Bailitz J, Chung AS, Mannix A, Battaglioli N, Clinton M, and financial or management relationships that could be perceived Gottlieb M. Wellness in resident education: an evidence-based guide as potential sources of bias. No author has professional or financial to best practices from the Council of Emergency Medicine Residency relationships with any companies that are relevant to this study. Directors. West J Emerg Med. 2020;21(2):299-309. There are no conflicts of interest or sources of funding to declare. 17. Estes M, Gopal P, Siegelman JN, Bailitz J, Gottlieb M. Individualized Copyright: © 2020 Natesan et al. This is an open access article interactive instruction: an evidence-based guide to best practices distributed in accordance with the terms of the Creative Commons from the Council of Emergency Medicine Residency Directors. West Attribution (CC BY 4.0) License. See: http://creativecommons.org/ J Emerg Med. 2019;20(2):363-8. licenses/by/4.0/ 18. Phillips R, Ball C, Sackett D, et al. Oxford Centre for Evidence-based Medicine – Levels of Evidence (March 2009). Available at: https:// www.cebm.net/2009/06/oxford-centre-evidence-based-medicine- REFERENCES levels-evidence-march-2009/. Accessed March 26, 2020. 1. Cooke M, Irby DM, Sullivan W, et al. American medical education 100 19. McLeod PJ, Harden RM. Clinical teaching strategies for physicians. years after the Flexner Report. N Engl J Med. 2006;355(13):1339-44. 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114. Nishisaki A, Donoghue AJ, Colburn S, et al. Effect of just-in-time videos’ content and approach to visualization. Clin Ophthalmol. simulation training on tracheal intubation procedure safety in the 2016;10:1535-41. pediatric intensive care unit. Anesthesiology. 2010;113(1):214223. 119. Patterson MD, Geis GL, Falcone RA, LeMaster T, Wears RL. In situ 115. Kessler D, Pusic M, Chang TP, et al. Impact of just-in-time and just- simulation: detection of safety threats and teamwork training in a high in-place simulation on intern success with infant lumbar puncture. risk emergency department. BMJ Qual Saf. 2013;22:468-77 Pediatrics. 2015;135(5):e1237-e1246. 120. Mishra S. Google Glass in medicine: the man with a computer on 116. Patocka C, Lin M, Voros J, Chan T. Point-of-care resource use in the face. Indian Heart J. 2016;68(4):586-7. emergency department: a developmental model. AEM Educ Train. 121. Dougherty B, Badawy SM. Using Google Glass in nonsurgical 2018;2:221-8. medical settings: systematic review. JMIR Mhealth Uhealth. 117. Campbell J, Umapathysivam K, Xue Y, Lockwood C. Evidence based 2017;5(10):e159. practice point-of-care resources: a quantitative evaluation of quality, 122. Sandars J. The use of reflection in medical education: AMEE Guide rigor, and content. Worldviews Evid Based Nurs. 2015;12(6):313-27. No. 44. Med Teach. 2009;31(8):685-95 118. Borgerson NJ, Vuokko Henriksen MJ, Konge L, et al. Direct 123. Adams RJ. Tele-attending can emulate and even improve bedside ophthalmoscopy on YouTube: analysis of instructional YouTube teaching and learning. Med Teach. 2018;40(10):1067-8.

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